Routine inspection·December 16, 2024

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Elena Bor and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents, with a Hospice Waiver for 6. The facility currently has 6 Residents, 5 of which receive Hospice Services. The facility is a two-story home located in Fullerton, Ca (only the first floor is licensed to provide care and supervision). A tour of the facility includes: Living room, 2 dining areas/room, 5 Resident Bedrooms (1 is a shared room), 4 full baths located in 4 of the resident bedrooms, 1 full bathroom, front yard, back yard, detached garage, and a pool (which is fully fenced). 2nd floor is private residence for Administrator. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: Facility has sufficient PPE supplies and Infection Control Plan maintained at the facility. Operatio nal Requirements: The facility has an approved fire clearance and maintain the required liability insurance. During resident file review it was observed that Resident #1 is bedridden, per their physician report dated 8/21/24, facility has fire clearance for Non-Ambulatory Residents Only, citation will be issued along with civil penalties as facility is operating outside of what they are approved for. Staffing : There appears to be sufficient staffing at all times in the facility. Personnel Records-Training : Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in dementia, hospice care, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Elena Bor certificate expires 6/17/24. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. Facility has a pool in the back yard that is completely fenced and locked. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and, 1/2 of the facility measured below the required range of 105-120 degrees F, measuring at 80-86 degrees F, citation will be issued. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 6/26/24 citation will be issued. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There is 1 bedridden at this facility. Facility has 5 residents using hospice services and maintain the required hospice care plan. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit will be documented in the LIC809D. Civil Penalties were issued during visit. Exit interview held and a copy of the report, LIC421IM (Civil Penalty Assessment), and appeal rights were provided to Administrator Elena Bor.